Measuring the elastic properties of fine wire

The elastic moduli of fine wires made from MP35N and 304SS used in implantable biomedical devices are assumed to be the same as those published in the literature. However, the cold working required to manufacture the wire significantly alters the elastic moduli of the material. We describe three experiments performed on fine wire made from MP35N and 304SS. The experimentally determined Young's and shear modulus of both wire types were significantly less than the moduli reported in the literature. Young's modulus differed by as much as 26%, and the shear modulus differed by as much as 14% from reported values.

Identity theft: when bad things happen to your patients' and employees' good name

What should healthcare facility security directors and administrators do when patients or employees are the victims of identity theft? Taking the right steps to safeguard personal data won't insulate your facility from ever having to deal with this growing crime but, says the author, it will reduce the opportunity and desire for a criminal to steal the data.

Isolation of Cladonema Pax-B genes and studies of the DNA-binding properties of cnidarian Pax paired domains

Pax genes encode nuclear transcription factors that are involved in developmental control. They contain a conserved DNA-binding domain, the paired domain. The DNA-binding specificity of paired domains is directly related to the gene regulation function of Pax proteins. Pax genes were previously divided into five groups on the basis of a phylogenetic analysis of paired domains. In this study, two highly similar cnidarian Pax-B genes from Cladonema californicum, a jellyfish with eyes, were found and sequenced. In an effort to understand the function of the cnidarian Pax genes isolated in this and a previous study, we characterized the consensus DNA sequences bound by the cnidarian paired domains using a PCR-based method and electrophoretic mobility shift assays. The consensus DNA sequences obtained are very similar to those bound by mammalian Pax proteins. Comparison of known consensus sequences indicates that they are all partially palindromic, but this characteristic is most prominent in cnidarians, which suggests that the DNA sequences bound by the ancestral paired domain could have been palindromic. Also, cnidarian paired domains, like those of Pax-2/5/8, possess a broader binding specificity than other paired domains, which implies that the common ancestor of Pax-2/5/8 and Pax-4/6 paired domains could also have had a similar broad DNA-binding specificity. Thus far, a definitive Pax-6 gene has not been found in several cnidarian species examined, which is consistent with a later origin of the Pax-6 gene and raises two possibilities: the Pax genes of cnidarians are multifunctional and control two or more developmental pathways, including eye development, or they use a Pax-independent pathway for eye development. Whether this pathway does exist and is unique to cnidarians or it whether it represents a true master control under which Pax-6 was later included remains to be determined.

Peer review of classroom teaching: an interim report

This paper provides interim findings from the implementation of peer review of classroom teaching in a large UK University School of Nursing, Midwifery and Health Visiting. A total of 258 classroom teaching sessions, involving 129 teaching staff (n=129) were included over a period of 7 months. Teachers had two teaching sessions reviewed by a colleague. One reviewer was self-nominated and the Dean of School allocated the other. The paper is in two parts. Part one includes a short literature review followed by a descriptive account of how peer review was implemented. Part two focuses upon individual experiences from a small scale study with data obtained from 14 teachers (n=14) who took part in qualitative interviews based on their experiences of being both reviewer and reviewee. The larger study gathered data from several sources. This paper presents the initial findings from interview data with nurse teachers. Their perceptions form the basis of a discussion, which raises issues related to the experience of both implementing and being involved in, peer review of classroom teaching. Four themes emerged from the interview transcriptions; peer review was initially perceived as a threat; the experience of peer review was a positive one; teachers felt that being a reviewer was an interesting and worthwhile experience and perceived peer review positively when good relations existed between them and their reviewer.

Nursing older dying patients: findings from an ethnographic study of death and dying in elderly care wards

Nursing older dying patients: findings from an ethnographic study of death and dying in elderly care wards Background and aim. The aim of the study was to explore the experiences of dying patients and nurses working in three elderly care wards focusing on the management of care for dying patients. The majority of patients who die in hospital are over the age of 65 and evidence suggests that three fifths are over the age of 75. Older patients pose tremendous problems and challenges to nurses and doctors regarding the provision of good terminal care, particularly in relation to developing effective communication.

METHOD

An ethnographic research design was chosen. The research sample consisted of 74 patients, 29 nurses and 8 physicians. The principle data collection methods were participant observation and semi-structured interviews. All respondents were interviewed following a period of observation on each of the ward areas. The data obtained from participant observation were then used to structure the interview questions. The purpose of asking questions about meanings associated with observational material was to evaluate the extent to which convergence or divergence of the data was taking place.

FINDINGS

The findings demonstrate that the care of older dying patients was defined by a lack of 'emotional engagement' with the patient and the institutionalized nondisclosure of information about death and dying. The study raises issues concerning the lack of effective communication about terminal diagnosis and the strategies used by nurses and doctors for disclosing information about death and dying. The findings suggest that although nurses provide individual care to dying patients, much of this was aimed at meeting patients' physical needs. Nurses reported psychosocial aspects including spiritual and emotional care to be important, although there was little evidence of them being orientated towards this in practice.

CONCLUSION

The indicative conclusions from this study suggest that terminal care for some elderly patients remains hampered by a reluctance of nurses and doctors to be more open in their communication about death. It would appear that hospital culture and the mores, beliefs and ideologies that emanate from the biomedical model, significantly shape the experiences of older dying patients.

Palliative care in a Mediterranean culture: a review of services in the Republic of Cyprus

This article reviews the provision of palliative care services in the Republic of Cyprus, highlighting healthcare resources in general and palliative care in particular. An interesting feature of palliative care in Cyprus is the extent to which community palliative care provision appears to be expanding and developing, with hospice care supplementing the work of home care nurses. The role of the home care nurse is discussed and the key role played in patient and family education highlighted. The article raises some interesting features of the relationship between bereavement and culture highlighting the influence that medicalization of health has on traditional ways of caring for patients with cancer and non-cancer conditions.

Grief and older people: the making or breaking of emotional bonds following partner loss in later life

The aim of this ethnographic study was to explore retrospectively the grief experiences of 12 older people whose partners had recently died in hospital, following a period of terminal illness. The rationale was based upon developing an understanding of the grief experiences of newly bereaved older people. In doing so, it is important to consider that grief is not only shaped by culture and social context but also by the nature of the relationship between the mourner and the deceased. For most of this century, the dominant conceptualization relating to grief and the social experience of bereavement has been based on the psychoanalytical school of thought. This process is said to involve the mourner passing through a number of stages or phases and forms the basis of the 'grief work hypothesis'. Using in-depth ethnographic interviews, the mourner's reactions to and perceptions of the loss were explored. Tape-recorded interview data were analysed using the inductive process of both content analysis and discourse evaluation. The findings from this study shed light on an area of conjugal bereavement that has received little attention in the past and challenges traditional models of grief. The indications are that in the first year of bereavement, the bereaved retain and modify the emotional relationship with their deceased partners, through a range of symbolic behaviours. The discussion raises issues concerning the need to consider the extent to which contemporary conceptualizations of grief explain the reactions of older people whose grief experiences are shaped by their social situation. The study also highlights important issues concerning the need to understand the complexity of grief experiences and bereavement support for older people which has a number of implications for nurses in both hospital and community settings.

Truth telling and the dying patient: a conspiracy of silence?

This article reports on the findings of an ethnographic study of the terminal care of older dying patients in hospital. The study focused on the information given to 22 patients diagnosed with a life-threatening illness. Using data from participant observation and ethnographic interviews, the research examined the strategies used to control information about terminal diagnosis. Several ethical implications were raised, such as truth telling and collusion. The article examines the implications of implementing ward disclosure norms based on closed awareness. It also considers the issues associated with developing a truth-telling culture.

An unusual case of enterococcal tricuspid valve endocarditis

A 52-year-old male smoker presented with a 10-week history of weight loss and malaise, together with a 1-week history of left-sided pleuritic chest pain, haemoptysis and mild dyspnoea. He had used intravenous drugs for a short time 30 years previously although he denied any intravenous drug use since. There was no other past medical history of note.

On examination, he was thin and appeared chronically unwell. He was apyrexial. There was a left pleural rub. There were no murmurs or stigmata of endocarditis. There were no other findings of note.

Full blood screen was normal apart from a white cell count of 11.2x109/litre (normal range 4.0–11.0x109/litre). Erythrocyte sedimentation rate was 52 mm/hr and C-reactive protein was 16 mg/litre (normal range <7.0 mg/litre). Urinalysis and urine culture were normal. The chest X-ray showed a circumscribed left lower zone lesion (Figure 1). Figure 2 shows the computed tomography appearance of the lesion.

At this stage, pulmonary malignancy was suspected (either a primary or secondary). The following day, two sets of blood cultures were taken in view of a low grade pyrexia. Enterococcus faecalis grew from all four bottles and the patient was started on intravenous amoxycillin.

Five days after admission a new soft pansystolic murmur at the left sternal edge was noted. Intravenous gentamicin was added. Transthoracic echocardiogram was normal but was repeated after an interval of 10 days in view of continuing low grade pyrexia and at this stage showed a vegetation adherent to the tricuspid valve (Figure 3).

The patient was treated with intravenous amoxycillin and gentamicin for a total of 6 weeks. He did not develop any further complications and has remained well at follow up.

Impact of preoperative education on pain management outcomes after coronary artery bypass graft surgery: a pilot

Patients have been found to receive inadequate analgesia despite moderate to severe pain after coronary artery bypass graft (CABG) surgery. The purpose of this pilot study was to evaluate a preadmission educational booklet for patients undergoing their first uncomplicated CABG. A randomized controlled trial (RCT) was undertaken at the largest cardiovascular centre in Canada. Repeated measures were used to compare data from 3 interviews: at baseline, day 3, and day 5. Patients were randomly assigned to one of 3 groups at the preadmission clinic 2 to 7 days before surgery: (1) generic hospital booklet and videotape (control), (2) control + pain booklet, or (3) control + pain booklet and interview; 45 subjects completed all 3 interviews. Measures were the McGill Pain Questionnaire-Short Form and the American Pain Society Patient Outcome Questionnaire. For all groups, analgesic administration was inadequate (19.89[13.37] mg morphine equivalents/24 hours) despite unrelieved pain (6.63[2.46], 0-10). However, patients receiving the interventions in addition to control care received 46% more analgesia than patients receiving control care alone and had fewer concerns about asking for help and taking analgesia. Changes were not required in the intervention booklet or measures.

'Healthy viewing?': experiencing life and death through a voyeuristic gaze

Recent times have witnessed a groundswell in the number of British television programmes that deal with the 'real life' experiences of people in various health care settings. Such programmes tend to focus upon the two interrelated strands of the experience of those who deliver professional care and those who are at the receiving end of it. The usual rationale given for such programmes is that they offer insights about the delivery of health care that are not readily accessible to members of the public. This article will look beneath the rationale and reasons offered by programme makers for the existence of such documentaries. It will explore insidious and questionable elements that go beyond revealing the 'lived experience' of professional carers and those for whom they care. Emerging from this is the challenging notion that such programmes deliver the opportunity to experience the vulnerability, suffering and even death of others through a voyeuristic gaze.

Prospects for improved therapy in chronic obstructive pulmonary disease by the use of levalbuterol

Like asthma, chronic obstructive pulmonary disease (COPD) is a chronic disease, the most prominent symptom of which is airway obstruction. Airway inflammation may be pathogenomic in both diseases, but only in COPD does inflammation predominate as a determinant of symptoms to make obstruction largely refractory to treatment. Despite a more limited degree of reversibility than in asthma, beta(2 )-agonists are used extensively to reduce airway obstruction and to achieve symptomatic improvement, with racemic albuterol being widely favored. In asthma, bronchodilation and bronchoprotection largely account for symptomatic benefit. In COPD, the capacity of racemic albuterol to ameliorate these symptoms is more limited and suppression of edema and of infiltration and activation of leukocytes acquire greater significance. During regular use of racemic albuterol in asthma, bronchoprotection diminishes progressively as hyperresponsiveness becomes increasingly pronounced, a process that is associated with an infiltration and activation of eosinophils. These paradoxic effects of racemic albuterol may be attributed to pharmacologic actions of the distomer, (S)-albuterol. As would be expected, homochiral (R)-albuterol (levalbuterol) is more potent and effective in asthma and may have significant advantages if used in COPD. A substantial (4-8-fold) reduction in the dose of levalbuterol anticipates lesser side effects and diminished risk in patients with cardiovascular disease. Additionally, the increased potency and duration of bronchodilation observed in asthma may extend to COPD. Finally, removal of the proinflammatory actions of (S)-albuterol may eliminate the persisting obstruction and decrease elastance that are associated with enhanced inflammation and may allow levalbuterol to suppress edema and diminish leukocyte activation more effectively.

Model organ description protocols for completion by transplant surgeons using organs procured from medical examiner cases

A significant number of donor organs emanate from the medical examiner's or coroner's offices, because victims of head injuries from vehicular accidents, falls, assaults, gunshot injuries, and unattended cerebrovascular accidents fall under the jurisdiction of the medical examiner or coroner. Unfortunately, many organ procurement organizations may not fully understand the legal responsibilities of the medical examiner. Most of the medical examiner or coroner cases could be used without compromising the medical-legal responsibilities of the medical examiner or coroner if a reliable description of the respective organ could be made after surgical removal by either having a pathologist present or by having the surgeon prepare a description of the respective organ. The objective of this paper is to present a series of protocols that have been designed to describe the heart, lungs, liver, kidney, and spleen for use by organ transplant surgeons. These protocols have proven to be highly successful in making more organs available for transplantation.

Variation in the measurements of basement membrane thickness and inflammatory cell number in bronchial biopsies

We do not have an estimate of how much tissue is needed for a reliable measure of bronchial epithelial reticular basement membrane (RBM) thickness or for counts of inflammatory cells. An assessment of the frequency distribution and variance of data from repeat measurements of RBM thickness and biopsy section inflammatory cell counts in cases with asthma (n=6), chronic obstructive pulmonary disease (COPD; n=5), and normal healthy subjects (n=7) was made. Tissue sections were stained with haematoxylin and eosin or by immunohistochemistry for EG2, mast cell tryptase and CD3-positive cells. Measurements of RBM thickness in individuals followed a log-normal distribution. For a precision of approximately +/-15%, 31-45 measurements were required. In contrast, inflammatory cell counts for each individual did not follow a normal distribution. There was high variance such that the cumulative weighted mean did not become stable until at least 5-10 mm of tissue underlying the RBM had been included. In conclusion multiple measurements of reticular basement membrane thickness or tissue section cell counts should be made for each individual in studies of bronchial biopsies. It is recommended that reticular basement membrane thickness should be measured at 20 mm intervals over a 1 mm reticular basement membrane length and that a zone beneath it of at least 5-10 mm of reticular basement membrane should be included for counts of inflammatory cells.

Inhibition of serum and transforming growth factor beta (TGF-beta1)-induced DNA synthesis in confluent airway smooth muscle by heparin

1. Airway remodelling occurs in asthma and involves an increase in airway smooth muscle mass through cell proliferation and hypertrophy. Increased eosinophil density in the airways is a feature of asthma. Eosinophils exhibiting activation in the airways of asthmatics also exhibit increased expression of transforming growth factor beta (TGF-beta1). We have examined the capacity of TGF-beta1 and epidermal growth factor (EGF) to influence airway smooth muscle division and the effect of heparin on TGF-beta1. EGF and serum-induced smooth muscle DNA synthesis in confluent airway smooth muscle cells (ASMC) as an indication of entry into S phase preceding mitogenesis. 2. ASMC were obtained from cell populations growing out from explanted bovine trachealis muscle sections. Cell division was monitored in sparse plated cells by direct cell counting following nuclear staining. Cell DNA synthesis in confluent cells was monitored by uptake of [3H]-thymidine. 3. TGF-beta1 (100 microM) inhibited FBS (10%)-induced smooth muscle division in sparsely plated cells (40%). TGF-beta1 (100 pM) increased cell DNA synthesis (200%) in confluent cells in the presence of bovine serum albumin (BSA, 0.25%). EGF (0.7 nM) also increased airway smooth muscle DNA synthesis (69%) in the presence of BSA (0.25%). The facilitatory effect of TGF-beta1 was observed between 1-100 pM, while that of EGF was observed between 20 200 pM. 4. Heparin inhibited serum and TGF-beta1-induced DNA synthesis in confluent ASMC (55%), consistent with our previous observation of inhibition of division in sparsely populated ASMC (Kilfeather et al., 1995a). This action of heparin was observed between concentrations of 1-100 microg ml(-1). Heparin did not inhibit DNA synthesis in response to EGF. An anti-mitogenic effect of heparin was also observed against responses to combined exposure to TGF-beta1 and EGF. 5. There was a clear inhibitory effect of heparin in absolute terms against serum-induced division in cells plated at 10, 20 and 45 x 10(3) cells cm(-2). The inhibitory effect of heparin was also observed at a plating density of 45,000 cells cm(-2) when responses to serum were expressed as fold-stimulation of basal DNA synthesis. 6. These findings demonstrate a potential role of TGF-beta1, EGF and heparin-related molecules in regulation of airway smooth muscle division.

Cardiotoxic mechanisms and interrelationships of cocaine: including a single case depicting several of these mechanisms

The underlying mechanisms of myocardial infarction as a result of cocaine abuse appear to be multifactorial. The various cardiotoxic mechanisms and interrelationships of cocaine are fully reviewed, and a chart has been reconstructed to give the reader a clearer understanding of them. Moreover, an unusual case of a 29-year-old male cocaine abuser is presented because it illustrates many of the reported cardiotoxic effects, all of which are present in the same individual.

Family partnership in care: integrating families into the coronary intensive care unit

Since the introduction of Family Partnership in Care in the CICU and other pilot units, many changes have been made. Education sessions are now unit specific rather than in groups with multiple units. This facilitates the discussion of unit-specific educational and implementation needs. In addition, unit-specific sessions allow for some case scenario/role playing activities to facilitate learning and application of the FPCP elements to the unique culture of the unit. Finally, less emphasis is placed on the documentation, while greater emphasis is placed on the philosophy behind the program and the nurses values and attitudes towards families. Overall, the implementation of the FPCP in CICU has had a positive impact on staff and patients. Staff awareness regarding the importance of involving family in the patient's care and the benefits of this has been heightened. Staff who were initially very skeptical have become strong advocates for the program. The successful shift with families in "doing for" to "working with" has enhanced the professional practice of many nursing staff and contributed to the overall unit functioning. Finally, the feedback from patients and their care partners and the independence and informed decision-making fostered by designing a plan of care with staff validates the importance of this program in a critical care area.

The effect of a novel orally active selective PDE4 isoenzyme inhibitor (CDP840) on allergen-induced responses in asthmatic subjects

Recent studies have suggested that theophylline, a nonspecific phospho-diesterase inhibitor, has useful anti-inflammatory actions in asthma. Phosphodiesterase 4 (PDE4) represents the predominant PDE isoenzyme present in inflammatory cells. PDE4 inhibitors might, therefore, have beneficial effects in asthma. Side-effects, specifically nausea, have limited the use of existing agents. CDP840 is an orally active, potent and selective PDE4 inhibitor. We have examined the effect of CDP840 on the allergen-induced asthmatic response, its possible modes of action, and its tolerability at therapeutic doses. A total of 54 patients were recruited to three double-blind, placebo-controlled studies. The first study examined the effect of CDP840 (15 mg b.i.d. for 9.5 days) on the allergen-induced asthmatic response in patients with known dual response to allergen. A second study examined the effect of CDP840 (15 mg b.i.d. for 9.5 days) on airway responsiveness to histamine. A third study examined whether single dose CDP840 (15 and 30 mg) had significant bronchodilatory effects. In all studies, CDP840 was well-tolerated, with no patients reporting nausea. CDP840 did not lead to changes in baseline forced expiratory volume in one second (FEV1) as compared to placebo. The late asthmatic response (LAR) to allergen, expressed as area under the curve at 3-8 h (AUC3-8h), was inhibited by 30% (p=0.016), an effect which persisted to the end of the observation period. The early asthmatic response (EAR) was unaffected, and there was no bronchodilatory effect at the doses used. Treatment with CDP840 did not affect bronchial hyperresponsiveness to histamine. In conclusion, CDP840 significantly attenuated the late asthmatic response to allergen challenge in the absence of any bronchodilatory or histamine antagonist effect. This suggests that CDP840 may exert its effects via an anti-inflammatory mechanism.

Complete remission of extensive metastatic renal cancer following immunotherapy

The authors describe the case history of a 54-year-old female patient, who presented with breathlessness, deteriorating general health and a 12 kg weight loss due to extensive metastatic renal cancer. Pulmonary emboli complicated the presentation. The patient entered a remarkable complete radiological remission by 18 weeks following the introduction of interleukin-2/alpha-interferon immunotherapy. The possibility of immediate nephrectomy or warfarin contributing to the augmentation of the effects of the immunotherapy is discussed.

Low-dose theophylline modulates T-lymphocyte activation in allergen-challenged asthmatics

Theophylline has been shown by several investigators to attenuate the late asthmatic response (LAR) to inhaled allergen, suggesting that it has anti-inflammatory or immunomodulatory properties. We have, therefore, undertaken a double-blind, placebo-controlled study to examine the effects of low-dose theophylline on bronchoalveolar lavage (BAL) and blood T-lymphocyte profile and activation in asthmatics following antigen challenge and the development of a LAR. Peripheral blood and BAL samples were obtained from 17 subjects with mild atopic asthma before and after 6 weeks of treatment with either oral theophylline or placebo. The mean serum theophylline concentration achieved was 6.6 micrograms.mL-1, which is below the currently accepted therapeutic range. Following theophylline therapy, there was a significant decrease in the number of BAL lymphocytes compared to placebo. On flow cytometric analysis of BAL cells, a significant loss of CD3+ T-lymphocytes, comprising both CD4+ and CD8+ subsets, was demonstrated. Moreover, there was a decrease in the number of BAL CD4+ T-cells expressing the activation marker very late activation antigen-1 (VLA-1), and an apparent reduction in human leucocyte antigen-DR (HLA-DR). Correspondingly, this was accompanied in the blood by an elevation in the proportion of activated CD4+ T-lymphocytes, in particular those expressing HLA-DR. These findings provide further evidence that theophylline has an anti-inflammatory action in asthma.

Identification of a killer by a definitive sneaker pattern and his beating instruments by their distinctive patterns

A 39-year-old male service station attendant was found murdered on the floor of a gasoline service area by a passing motorist who had stopped for gas. The victim had been brutally beaten all over his entire body. After carefully examining the body and scene and taking selective photographs, special procedures were implemented in an attempt to preserve and transport the body without disturbing any items of evidence. In addition, specific evidentiary items were noted and collected for processing. The victim was meticulously examined externally at autopsy using a special protocol to locate clues that might assist in identifying a suspect or instrument of injury or death. Patterned impressions and subsequent DNA analysis proved successful in identifying the perpetrator of the crime and the instruments used in inflicting the beating. It is the purpose of this paper to show how a meticulous examination of the body for the presence of patterned injuries and critical studies of these patterns and impressions led to the identification of a killer and the instruments he used in a brutal beating.

Helping relatives cope with the grieving process

Grief may be a natural reaction to loss, felt by those most affected, within their own cultural context. Stage-theory approaches to grief may encourage people to think of grief in a simplistic or inflexible way. It is important to allow patients to make their own responses and to express their feelings.

Mortality of a cohort of U.S. workers employed in the crushed stone industry, 1940-1980

The mortality of 3,246 males who had been employed 1 or more years during 1940-1980 at 20 crushed stone operations was evaluated for possible association between employment and death from lung cancer, pneumoconiosis, and other respiratory diseases. Four deaths were attributed to pneumoconiosis. Based on available work histories, at least two of these deaths were probably due to dust exposures in the crushed stone industry. Mortality attributed to pneumoconiosis and other nonmalignant respiratory diseases, including chronic obstructive lung disease, was significantly increased overall (SMR: 1.98; 95% CI: 1.21-3.05), and especially so for a subcohort of crushed stone workers that processed granite (SMR: 7.26; 95% CI: 1.97-18.59). With regard to lung cancer, overall SMRs were elevated (although not statistically significant). Analyzed by rock type, there was a significantly elevated lung cancer SMR among granite workers with at least 20 years latency (SMR: 3.35; 95% CI: 1.34-6.90). Although not definitive, results of this study are consistent with the hypothesis that exposure to respirable silica dust is a risk factor for lung cancer.

Occupational exposures to fibers and quartz at 19 crushed stone mining and milling operations

From 1979 to 1982, the National Institute for Occupational Safety and Health (NIOSH) conducted a cross-sectional exposure assessment and mortality study of selected crushed stone facilities in the United States. This study was undertaken in part to address concerns that asbestos exposures could be occurring in some crushed stone operations due to the presence of amphibole and serpentine minerals. The investigation was also designed to characterize exposures to crystalline silica and other mineral compounds. Nineteen crushed stone operations, mining limestone, granite, or traprock were surveyed to assess exposures to respirable and total dusts, mineral compounds including crystalline silica, asbestos, and mineral fibers. At the initiation of the study, crushed stone operations were selected from a Mine Safety and Health Administration (MSHA) listing of the active industry in 1978. With the exception of requiring inclusion of the traprock operation in Maryland where asbestos fibers were initially discovered, a stratified sample of operations was randomly selected by rock type (granite, limestone, traprock, or sandstone). However, because of reluctance or refusal of some companies to participate and because of the closures of some of the selected operations, replacements were randomly selected. Some replacement selections were likewise replaced due to lack of cooperation from the companies. The studied sample included only 10 of the 27 randomly selected operations in the original sample. Asbestos fibers were detected at one traprock facility, the Maryland operation where asbestos was originally found. Measured personal exposures to fibers exceeded the NIOSH Recommended Exposure Limit (REL) for two out of 10 samples. All of the samples were below the MSHA Permissible Exposure Limit (PEL), which was in effect at the time of the survey. However, due to the presence of nonasbestos mineral fibers in the environment, it could not be stated with certainty that all of the fibers counted by phase contrast microscopy were asbestos. A variety of silicate mineral fibers (other than those classified by NIOSH as asbestos) were detected in the traprock operations and at one granite operation. Crystalline silica was detected at 17 of the 19 surveyed crushed stone operations. Overexposures to crystalline silica were measured at 16 of the crushed stone operations; approximately one in seven personal-respirable dust samples (14%) exceeded the MSHA PEL for crystalline silica. Approximately 25% of the respirable dust samples exceeded the NIOSH REL for crystalline silica. Mill operators and mill laborers consistently had the highest and most frequent overexposures to crystalline silica.

Identification of a homicide victim by a Casio data bank watch

A positive identification of a homicide victim was made possible by observing an inconspicuous Casio watch worn by the deceased. Identification of deceased individuals are usually made by fingerprints or dental matching, visual means, DNA studies, X-rays of other bodily structures, tattoos, etc. When all of these methods fail and no suspects are known, medical examiners are caught between Charybdis and Scilla. This assumes greater importance in cases of homicides. It is the purpose of this paper to present a homicide case in which an identification was made by observing an inconspicuous object, a small Casio watch worn by the deceased.

Anti-inflammatory effects of low-dose oral theophylline in atopic asthma

Theophylline, in addition to its bronchodilator effect, may attenuate inflammation in asthma. We did a double-blind placebo-controlled study of the effect of oral theophylline on the inflammatory response of the bronchial mucosa to inhalation of allergen in 19 atopic asthmatic subjects. Bronchoscopy and bronchial biopsy were done 24 hours after allergen inhalation before and after six weeks of treatment with oral slow-release theophylline, 200 mg 12 hourly. The mean serum concentration was 36.6 mumol/L, which is below the currently-accepted therapeutic range. After treatment with theophylline there was a significant reduction in the number of EG2-positive activated eosinophils (5.9 before and 2.1 after treatment, Wilcoxon signed rank p < 0.05) and total eosinophils (16.7 before and 7.6 after treatment, p < 0.05) beneath the epithelial basement membrane. We conclude that low-dose oral theophylline attenuates airway inflammatory response to allergen inhalation in atopic asthma.

Regional cerebral perfusion abnormalities after cardiac operations. Single photon emission computed tomography (SPECT) findings in children with postoperative movement disorders

Despite the clinical and pathologic indicators implicating injury to the basal ganglia in children with hyperkinetic movement disorders, we were previously unable to identify lesions in these structures by means of cranial computed tomography or magnetic resonance imaging. We evaluated regional cerebral perfusion measured by single photon emission computed tomography (SPECT) with technetium 99m hexamethyl propylene amine oxime as a technique to localize functional cerebral abnormalities in eleven children who had a movement disorder after hypothermic cardiac surgery. Perfusion defects of the deep gray matter were noted in six of these eleven patients and cortical perfusion defects in nine. For both cortical and subcortical defects a strong right-sided predilection was present. Our findings suggest functional brain injury not detectable by conventional cranial computed tomography and magnetic resonance imaging in these patients. We speculate that these perfusion defects might relate to the behavioral and developmental sequelae in survivors of this syndrome. SPECT may identify subclinical injury in patients at risk for future neurodevelopmental problems and contribute to our understanding of the mechanisms of cerebral injury in the patient operated on for cardiac disease.

Myocardial perfusion, function and exercise tolerance after the arterial switch operation

OBJECTIVES

This study was conducted to determine the prevalence of myocardial perfusion abnormalities at rest and exercise and to assess exercise capacity in children after the arterial switch operation.

BACKGROUND

There have been sporadic reports of myocardial ischemia or sudden death in children after the arterial switch operation for transposition of the great arteries, possibly related to inadequate coronary perfusion due to kinking or stenosis of the translocated coronary arteries.

METHODS

Myocardial perfusion at rest and peak exercise was assessed using the scintigraphic agent technetium-99m methoxyisobutyl isonitrile (sestamibi). Exercise capacity was determined with a modified Bruce protocol. Ambulatory electrocardiographic (ECG) Holter monitoring was performed. Ventricular function, contractility and wall motion were assessed echocardiographically.

RESULTS

Twenty-three children (aged 4.2 to 7.9 years) underwent evaluation. Abnormalities were found on the rest perfusion scans in 22 children (95.6%). The left ventricular myocardium was divided into 13 segments for analysis. Of 299 rest segments, 225 (75.3%) were normal, 11 (3.7%) showed mild defects, 45 (15%) moderate defects and 18 (6%) severe defects at rest. At peak exercise, 237 segments (79.3%) were normal, 24 (8%) showed mild defects, 33 (11%) moderate defects and 5 (1.7%) severe defects. Compared with rest studies, myocardial perfusion grade at exercise was unchanged in 246 segments (82.3%), improved in 42 (14%) and worsened in 11 (3.7%). All patients had normal exercise tolerance without symptoms or ischemic ECG changes. No ventricular tachycardia was seen on Holter monitoring. All patients had a shortening fraction > or = 27%. Left ventricular contractility was normal in 12 children in whom it was assessed. Regional wall motion was normal in 17 children with adequate echocardiographic images for this analysis.

CONCLUSIONS

Myocardial perfusion scan abnormalities assessed by technetium-99m sestamibi are common after an arterial switch operation. These abnormalities are of uncertain clinical significance and generally lessen with exercise. The normal exercise tolerance without symptoms or ECG changes suggests that myocardial perfusion is adequate during the physiologic stress of exercise in children up to 8 years after an arterial switch operation.

Transdermal nicotine patches with low-intensity support to aid smoking cessation in outpatients in a general hospital. A placebo-controlled trial

OBJECTIVE

To assess whether transdermal nicotine patches combined with low-intensity support can help outpatients in a general hospital stop smoking.

DESIGN

Randomized, double-blind, placebo-controlled trial with 12 weeks of follow-up.

SETTING

Department of Thoracic Medicine in an inner-city public general hospital, London, England.

SUBJECTS

Two hundred forty-eight outpatients in a general hospital, who smoked at least 10 cigarettes per day (the majority were being treated for smoking-related diseases), referred by clinicians at the hospital.

INTERVENTION

Brief advice to stop smoking and daily application of transdermal nicotine patches (delivering 15 mg over 16 hours) or placebo, with follow-up appointments at 1, 3, 6, and 12 weeks, with a doubling of the dosage for continuing smokers at week 1.

MAIN OUTCOME MEASURE

Sustained abstinence from tobacco from week 3 to week 12 validated with measurement of expired-air carbon monoxide concentration at weeks 3, 6, and 12.

RESULTS

Twenty-nine (23.4%) of 124 subjects assigned to the nicotine group were validated as having abstained from smoking at both weeks 3 and 6, compared with 16 (12.9%) of 124 subjects receiving placebo (P = .008). At week 12, 22 (17.7%) of the subjects in the nicotine group were validated as having abstained at all three points as were 15 (12.1%) of the subjects in the placebo group (P = .058).

CONCLUSION

Transdermal nicotine patches combined with low-intensity support are effective in helping outpatients in a general hospital stop smoking but do not prevent relapse after 6 weeks.

The Effect of Preceptorship Upon Diploma Program Nursing Students' Transition to the Professional Nursing Role

This quasi-experimental study determined the effect of a 17-week pregraduate preceptorship program upon diploma nursing students' (N = 22) performance of the professional nursing role. Nine students participated in the preceptorship program; 13 received the standard pregraduate clinical experience. Nursing performance was measured using Schwirian's Six Dimension Scale of Nursing Performance prior to, during, and upon completion of the pregraduate clinical experience. Based on the faculty adviser's appraisals, the preceptorship program was associated with significantly greater improvements in nursing performance within the teaching/collaboration and planning/evaluation dimensions.

Boarding out as an option for the care of elderly people

There has been some experiment in Ireland in recent years with boarding out of elderly persons. This comprises the placement, usually with a non-relative in a private household, of an elderly person, with the carer receiving some reward. This study assesses the cost of care for a small group of elderly persons in boarding-out care compared with a similarly dependent group of elderly persons in welfare home institutional care. The cost of boarding out care is less than half the cost of care in the welfare home. This result is encouraging given the feeling that quality of care in boarding out is not below that of institutional care.

Silicosis and lung cancer in U.S. metal miners

The association between silicosis and lung cancer mortality was estimated in 9,912 (369 silicotics and 9,543 nonsilicotics) white male metal miners. These miners were examined by the U.S. Public Health Service during 1959-1961 and were followed through 1975. Miners were excluded from this study if they were employed in a mine during 1959-1961 that used diesel equipment underground. The ores that were mined consisted of copper, lead-zinc, iron, mercury, lead silver, gold and gold-silver, tungsten, and molybenum. The standardized mortality ratio (SMR, U.S. white male rates) for lung cancer was 1.73 (95% CI: .94-2.90) in silicotics and 1.18 (95% CI: .98-1.42) in nonsilicotics. Additionally, SMRs were higher in silicotics than in nonsilicotics, even in most subgroups stratified by cigarette smoking habit, type of ore mined, years of service in an underground job, radon exposure group, or year of hire. When lung cancer mortality between silicotics and nonsilicotics was compared, the age-adjusted rate ratio (95% CI) was 1.56 (.91-2.68), and the age- and smoking-adjusted rate ratio was 1.96 (.98-3.67). Corresponding figures for miners who were employed in mines with low levels of radon exposure were 1.90 (.98-3.67) and 2.59 (1.44-4.68), respectively. These findings indicate that lung cancer mortality risk was increased in silicotics, and this probably did not result from chance or bias. However, confounding from radon exposure could not be ruled out. The findings indicate that further follow-up of this cohort is needed.